Seizure Disorders

Rescue Medication in Children at Risk of Prolonged Convulsive Seizures

Author:

J Gordon Millichap

Northwestern University Feinberg School of
Medicine, US

Abstract

Investigators at the Institute of Child Health, Great Ormond Street Hospital, London, and other centers in the UK and Europe, explore the adequacy of treatment of children with prolonged convulsive seizures (defined as seizures lasting more than 5 min) occurring in school to prevent progression to status epilepticus and neurological morbidity.

Investigators at the Institute of Child Health, Great Ormond Street Hospital, London, and other centers in the UK and Europe, explore the adequacy of treatment of children with prolonged convulsive seizures (defined as seizures lasting more than 5 min) occurring in school to prevent progression to status epilepticus and neurological morbidity. Already known is that medication should be given as quickly as possible, and administration of rescue medication in school depends on presence of a trained caregiver. Existing national recommendations include a parent’s responsibility to request treatment for a child as needed, to provide all necessary medical information from the treating physician, and teacher volunteers responsible for administering medication should receive training from the school nurse or local health service. Areas for improvements include: 1) practical information to schools on treatment of prolonged convulsive seizures, 2) individual healthcare plan for the child, 3) a clear link between treating physician and school for each child who requires rescue medication, 4) responsible caregiver to receive specific training on rescue medication, 5) comprehensive guidance to ensure immediate treatment wherever seizure occurs, and 6) need for more information on the experience of children, teachers, and emergency services regarding management of prolonged convulsive seizures occurring at school. [1]

COMMENT. In the past, a seizure lasting 30 min or longer was considered status epilepticus. Currently, experts classify any episode of seizure activity lasting 5 min or longer as status epilepticus. Once seizures persist for 5 to 10 min, they are unlikely to stop without treatment. Pre-hospital treatment with benzodiazepines will reduce seizure activity whereas delayed treatment is less successful, with risk of subsequent prolonged seizure activity, memory deficit, and learning difficulties. [2]

A >15 min duration of a febrile seizure is one criterion for the definition of a complex seizure, but a recent FEBSTAT study supports a redefining of simple vs complex seizure, limiting the duration of a simple febrile seizure to no longer than 10 min. [3]

Spontaneous seizures and febrile seizure duration. Data in support of a shorter 5-10 min cut off for a simple FS were obtained in a comparative study of 86 consecutive patients with FSs of short and long duration [4, 5]. In 38 patients with FS <5 min duration, 7.9% developed spontaneous seizures; in 21 with FS 5-10 min duration, 9.5%; in 14 with FS 10-20 min duration, 14%; and in 13 with FS >20 min duration, 38% had spontaneous seizures. The difference in spontaneous seizure incidence in patients with FS of 5 and 10 min duration was not significant whereas that between the 10 and >20 min FS duration was very significant. The prompt treatment within 5-10 min of onset of a convulsive seizure (febrile or non-febrile) is recommended, using an age-appropriate benzodiazepine preparation (rectal diazepine. intranasal lorazepam, or buccal midazolam) [6]. For the optimal outcome of children at risk of prolonged convulsive seizures, rescue treatment for administration at home or in the school should be available.